197610101-5-9-2023-31-AS-NMAN-CUGVM6-20230807163302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610101
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:02:18 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/02/2023 and conducted by Evaluator Abeye Duguma

COMPLAINT CONTROL NUMBER: 31-AS-20230502160633

FACILITY NAME:	HAMLIN ELDER CARE		FACILITY NUMBER:	197610101
ADMINISTRATOR:	BIGORNIA, LIMA ROSE		FACILITY TYPE:	740
ADDRESS:	20300 HAMLIN ST.		TELEPHONE:	(818) 912-6289
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 2	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Lima Rose Bigornia		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Improper eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced initial complaint visit to the facility to investigate the above allegation. LPA met with the administrator, Lima Rose Bigornia, and explained the reason for the visit.

---Improper eviction

It was alleged that the Resident #1 (R1) was locked out and sent to a hotel. To investigate the allegation on 05/09/2023, LPA requested and reviewed documents at 10:00 AM, interviewed two (02) staff from 11:00 AM – 12:00 PM and interviewed other parties at around 12:30 PM. File review revealed that R1 signed a short-term agreement from 03/27/2023 – 04/26/2023. LPA also discovered an Admissions Agreement which explains the proper eviction procedure.

(CONT. on LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230502160633

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAMLIN ELDER CARE	FACILITY NUMBER: 197610101
	VISIT DATE: 05/09/2023

NARRATIVE

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LPA did not find a copy of an eviction notice in R1’s file and when LPA asked for a copy of the eviction agreement, Staff #1 (S1) could not produce one. During interviews with Staff #1, they stated that R1’s stay was supposed to be temporary, that staff packed up R1’s belongings and a family member picked them up and took them to a hotel. S1 also admitted that facility did not issue an eviction notice. Staff #2 stated that they did not know the details of the eviction and directed LPA to speak with S1. During interviews with other parties, they stated that facility accepted R1on a temporary basis but R1 was willing to pay more money to stay longer. Other parties also stated that before R1 could pay to extend their stay, S1 had all their belongings packed up and waiting by the door for a family member to pack into the car. Other parties stated that R1 called the police, but they didn’t do anything. Other parties added that R1 was blind sided by the eviction, didn’t know what was going on and that R1 is now staying at an independent living facility.

Based on record review and interviews, there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230502160633

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HAMLIN ELDER CARE	FACILITY NUMBER: 197610101
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/16/2023 Section Cited CCR 87224(f)	1 2 3 4 5 6 7	87224(f) Eviction Procedures. A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to provide a written statement to CCL by the indicated due date confirming their understanding and intent to abide by the cited regulation.
	8 9 10 11 12 13 14	Based on interviews and record review the licensee did not comply with the section cited above by not notifying the licensing department of R1's eviction. This poses a potential Health and Safety and Personal Right risk to residents in care.	8 9 10 11 12 13 14
Type B 05/16/2023 Section Cited CCR 87224(a)(1)	1 2 3 4 5 6 7	Eviction Procedures: The licensee may evict resident for one or more of the reasons listed in Section 87224 (a)(1) - (5). 30 days written notice to the resident as required except as otherwise specified in paragraph (5): (1) Non payment of the rate for basic services within 10 days of the due date.	1 2 3 4 5 6 7	Licensee agreed to provide a written statement to CCL by the indicated due date confirming their understanding and intent to abide by the cited regulation.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by; Based on interviews, R1 was willing to pay to extend their stay, evicted based on the short-term agrement and forced to leave facility. This poses a potential Health and Safety and Personal Right risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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